Discharge Medication Reconciliation Resources

Corresponding PPMI Recommendations

B23K: Medication reconciliation in the emergency department; upon admission, interhospital transfer, and discharge; and in the ambulatory care setting

Wisconsin Transitions of Care Survey Results

73% of hospitals in Wisconsin are interested in expanding or implementing discharge medication reconciliation practices in their pharmacy department

54% of hospitals in Wisconsin currently perform discharge medication reconciliation with their pharmacy department

Guideline Statements

“Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten."1

As medication experts, pharmacists can play a tremendous role in ensuring the integrity of the medication list across care transitions.

Evidence supports the involvement of pharmacy staff at medication reconciliation with added focus on patients at high risk for adverse events.2 Pharmacist-led medication review is associated with a positive effect on medication use and cost.3 The American College of Clinical Pharmacy provides the following recommendation: Although the medication reconciliation process may be carried out by other members of the health care team, pharmacists play a vital role in ensuring the accuracy and appropriateness of a medication list. The Joint Commission does not specify who should be the “owner” of the medication reconciliation process, but only that a process should exist. Although other health professionals, including medical assistants, can take a medication history, pharmacists have the specialized drug knowledge to ensure the completeness and accuracy of the medication history. New information regarding the medication history should always be communicated to other members of the health care team.4